WHO Validates Elimination of Mother-to-Child Transmission of HIV and Syphilis in CubaWorld Health OrganizationJune 30, 2015

Cuba today became the first country in the world to receive validation from WHO that it has eliminated mother-to-child transmission of HIV and syphilis.

“Eliminating transmission of a virus is one of the greatest public health achievements possible,” said Dr Margaret Chan, WHO Director-General. “This is a major victory in our long fight against HIV and sexually transmitted infections, and an important step towards having an AIDS-free generation” she added.

Michel Sidibé, Executive Director of UNAIDS: “This is a celebration for Cuba and a celebration for children and families everywhere. It shows that ending the AIDS epidemic is possible and we expect Cuba to be the first of many countries coming forward to seek validation that they have ended their epidemics among children.”

The challenge

Every year, globally, an estimated 1.4 million women living with HIV become pregnant. Untreated, they have a 15-45% chance of transmitting the virus to their children during pregnancy, labour, delivery or breastfeeding. However, that risk drops to just over 1% if antiretroviral medicines are given to both mothers and children throughout the stages when infection can occur. The number of children born annually with HIV has almost halved since 2009 - down from 400 000 in 2009 to 240 000 in 2013. But intensified, efforts will be required to reach the global target of less than 40 000 new child infections per year by 2015.

Nearly 1 million pregnant women worldwide are infected with syphilis annually. This can result in early fetal loss and stillbirth, neonatal death, low-birth-weight infants and serious neonatal infections. However, simple, cost-effective screening and treatment options during pregnancy, such as penicillin, can eliminate most of these complications.

Cuba’s achievement

WHO/PAHO has been working with partners in Cuba and other countries in the Americas since 2010 to implement a regional initiative to eliminate mother-to-child transmission of HIV and syphilis.

As part of the initiative, the country has worked to ensure early access to prenatal care, HIV and syphilis testing for both pregnant women and their partners, treatment for women who test positive and their babies, caesarean deliveries and substitution of breastfeeding. These services are provided as part of an equitable, accessible and universal health system in which maternal and child health programs are integrated with programs for HIV and sexually transmitted infections.

“Cuba’s success demonstrates that universal access and universal health coverage are feasible and indeed are the key to success, even against challenges as daunting as HIV,” said PAHO Director, Dr Carissa F. Etienne. “Cuba’s achievement today provides inspiration for other countries to advance towards elimination of mother-to-child transmission of HIV and syphilis”.

Global efforts to stop mother-to-child transmission of HIV and syphilis

There have been major efforts in recent years to ensure that women get the treatment they need to keep themselves well and their children free from HIV and syphilis and a number of countries are now poised to eliminate mother-to-child transmission of both diseases.

In 2007, WHO launched the Global elimination of congenital syphilis: rationale and strategy for action. The strategy aims to increase global access to syphilis testing and treatment for pregnant women. By 2014, more than 40 countries were testing 95% or more of pregnant women in prenatal care for syphilis. But although progress has been made, many countries have still to prioritize preventing and treating mother-to-child transmission of syphilis. In 2012, syphilis affected 360 000 pregnancies through stillbirths, neonatal deaths, prematurity, and infected babies.

In 2011, UNAIDS with WHO and other partners launched the Global Plan towards the elimination of new HIV infections among children by 2015, and keeping their mothers alive. This global movement has galvanized political leadership, innovation and engagement of communities to ensure that children remain free from HIV and that their mothers stay alive and well.

Between 2009 and 2013, the proportion of pregnant women living with HIV in low- and middle-income countries receiving effective antiretroviral medicines to prevent transmission of the virus to their children doubled. This means that globally, 7 out of 10 pregnant women living with HIV in low- and middle-income countries receive effective antiretroviral medicines to prevent transmission of the virus to their children. Among the 22 countries which account for 90% of new HIV infections, 8 have already reduced new HIV infections among children by over 50% since 2009, based on 2013 data, and another four are close to this mark.

WHO validation process

In 2014, WHO and key partners published Guidance on global processes and criteria for validation of elimination of mother-to-child transmission of HIV and syphilis, which outlines the validation process and the different indicators countries need to meet.

As treatment for prevention of mother-to-child-transmission is not 100% effective, elimination of transmission is defined as a reduction of transmission to such a low level that it no longer constitutes a public health problem.

An international expert mission convened by PAHO/WHO visited Cuba in March 2015 to validate the progress toward the elimination of mother-to-child transmission of HIV and syphilis. During a five-day visit, members visited health centers, laboratories, and government offices throughout the island, interviewing health officials and other key actors. The mission included experts from Argentina, the Bahamas, Brazil, Colombia, Italy, Japan, Nicaragua, Suriname, the United States of America and Zambia.

The validation process paid particular attention to the upholding of human rights, in order to ensure that services were provided free of coercion and in accordance with human rights principles.

Note:

Required validation indicators include:

HIV
Impact Indicators – must be met for at least 1 year

New paediatric HIV infections due MTCT of HIV are less than 50 cases per 100 000 live births; and
MTCT rate of HIV to less than 5% in breastfeeding populations or less than 2% in non-breastfeeding populations
Process Indicators – must be met for at least 2 years • More than 95% of pregnant women, both who know and do not know their HIV status, received at least one antenatal visit • More than 95% of pregnant women know their HIV status • More than 95% of HIV-positive pregnant women receive antiretroviral drugs

Syphilis
Impact Indicators – must be met for at least 1 year

Rate of MTCT syphilis are less than 50 cases per 100 000 live births
Process Indicators – must be met for at least 2 years

More than 95% of pregnant women received at least one antenatal visit
More than 95% of pregnant women are tested for syphilis
More than 95% of pregnant women with syphilis receive treatment.
The term “validation” is used to attest that a country has successfully met criteria (internationally set targets for validation) for eliminating MTCT of HIV and/or syphilis at a specific point in time, but countries are required to maintain ongoing programmes.

In 2013, only two babies were born with HIV in Cuba, and only 5 babies were born with congenital syphilis.